Online Application - Volunteer Positions Only
        Click Here to view your online application.
 

Information is being submitted using IP:38.103.63.17 at 11:31:44 AM on 5/18/2008.
* Required Field
Personal Information
First Name* Middle Name Last Name*  
     
 
Address* City* State* Zip Code*
       
 
Home Phone* Work Phone Email*  
   
 
Age/Driver/Conviction Information
IF ACCEPTED AS A MEMBER, CAN YOU PROVIDE PROOF THAT YOU ARE AT LEAST 18 YEARS OF AGE?
Yes No
 
DO YOU POSSESS A VALID NC DRIVERS LICENSE?
Yes No 
 
HAS YOUR LICENSE EVER BEEN RESTRICTED OR REVOKED?
Yes No      If yes, please explain:
 
HAVE YOU RECEIVED ANY TICKETS IN THE LAST THREE YEARS?
Yes No      If yes, please explain:
 
HAVE YOU EVER BEEN CHARGED WITH AND/OR CONVICTED OF:  Check all that apply
DWI DWLR Reckless Driving Traffic Charge Resulting in Death Criminal Misdemeanor Criminal Felony
If you checked any of the above, please explain:
 
Education/Certification Information
HIGHEST EDUCATION LEVEL COMPLETED:
9 10 11 12 AAS BS/BA GRAD
 
CERTIFICATIONS AND TRAINING RELEVANT TO POSITION APPLIED FOR:  Check all that apply
NC-EMT EMT-I EMT-P BTLS ACLS PALS CPR Hurst Tool | Others:
* A valid NC-EMT certification is required to apply.
 
Employment History
CURRENT EMPLOYER
Name* Address* Phone* Job Title*
       
Supervisor* Duties* Reason for Leaving  
   
 
PAST EMPLOYER 1
Name Address Phone Job Title
Supervisor Duties Reason for Leaving  
 
PAST EMPLOYER 2
Name Address Phone Job Title
Supervisor Duties Reason for Leaving  
 
Personal References (Do not include former employers or relatives.)
REFERENCE 1*
Name Phone Address
REFERENCE 2*
Name Phone Address
REFERENCE 3*
Name Phone Address
 
Medical Information
DO YOU HAVE ANY PHYSICAL CONDITIONS THAT YOU ARE CURRENTLY BEING TREATED FOR OR TAKE MEDICATIONS AS PRESCRIBED BY A PHYSICIAN FOR SUCH CONDITIONS AS BUT NOT LIMITED TO DIABETES, EPILEPSY, HIGH BLOOD PRESSURE, HEART PROBLEMS ETC.?
 Yes No    If yes, please explain:
 
LIST ANY MEDICATIONS
 
Application Agreement

I CERTIFY THAT MY STATEMENT AND ANSWERS ARE ACCURATE TO THE BEST OF MY KNOWLEDGE AND THAT ANY MISREPRESENTATION, OMISSION OR FALSIFICATION OF INFORMATION WILL BE GROUNDS FOR DENIAL APPLICATION OR DISMISSAL FROM MATTHEWS RESCUE AND EMS.  I ALSO GIVE MY PERMISSION TO MATTHEWS RESCUE AND EMS, MATTHEWS POLICE DEPARTMENT AND THEIR REPRESENTATIVES TO VERIFY ANY AND ALL INFORMATION PROVIDED.  I ALSO UNDERSTAND THAT I MAY BE REQUIRED TO SUBMIT TO TESTS ADMINISTERED BY MATTHEWS RESCUE AND EMS THAT PERTAIN TO MY ABILITIES TO FUNCTION AS A FIRST RESPONDER FOR MATTHEWS RESCUE AND EMS.  THESE TEST MAY INCLUDE DRUG SCREENING, WRITTEN EXAMS, PHYSICALS OR ANY OTHER TEST DEEMED JOB RELATED.